Use of Combined Do-Not-Resuscitate/Do-Not Intubate Orders Without Documentation of Intubation Preferences: A Retrospective Observational Study at an Academic Level 1 Trauma Center Code Status and Intubation Preferences.

BACKGROUND: Combining orders for do-not-resuscitate (DNR) for cardiac arrest with do-not-intubate (DNI) orders into a DNR/DNI code status is not evidence-based practice and may violate patient autonomy and informed consent when providers discuss intubation only in the context of CPR. RESEARCH QUESTION: How often do providers refer to patients with a DNR order as "DNR/DNI" without documentation of refusal of intubation for non-arrest situations? METHODS: Retrospective observational study of adults (18 years of age or older) hospitalized in a Level 1 trauma/academic hospital between July 2017 and June 2018 inclusive with DNR orders placed during hospitalization. RESULTS: Of 422 hospitalized adults with DNR orders, 261 (61.9%) had code status written in progress notes as DNR/DNI. Providers' use of the term DNR/DNI in progress notes was significantly (OR, 2.21; 99% CI, 1.12-4.37) more common on medical hospital services (hospitalist, family medicine, internal medicine) than on nonmedical ward services (medical/surgical ICUs, surgery, psychiatry, neurology services). Of 261 "DNR/DNI" patients, providers did not document informed refusal of intubation for nonarrest situations for 68 (26.0%) of patients. By comparison, of 161 patients for whom providers documented code status in progress notes as DNR alone, 69 (42.9%) did have documentation of refusal of intubation for nonarrest events. Therefore, if a DNR/DNI code status was used in a nonarrest emergency to determine whether to intubate a patient, 68 (16.1%) of 422 patients could inappropriately be denied intubation without informed refusal (or despite their informed acceptance), and 69 (16.4%) could inappropriately be intubated despite their documented refusal of intubation. CONCLUSIONS: Conflation of DNR and DNI into DNR/DNI does not reliably distinguish patients who refuse or accept intubation for indications other than cardiac arrest, and thus may inappropriately deny desired intubation for those who would accept it, and inappropriately impose intubation on patients who would not.

Underutilization of Portable Orders for Life-Sustaining Treatment at Discharge from Hospital: Observational Study at US Academic Trauma Center.

BACKGROUND: Decisions to limit use of life-sustaining treatment occur frequently during hospitalizations, and portable medical orders (also known as Portable Orders for Life-Sustaining Treatment (POLST)) can ensure that patient preferences regarding resuscitation are followed after discharge. OBJECTIVE: To determine the frequency and predictors of completion of POLST orders for adults with change during hospitalization in resuscitation status to Do Not Resuscitate. DESIGN: Retrospective observational study at level 1 trauma and academic hospital in Minneapolis, MN, USA PARTICIPANTS: All adults (18 years or older) hospitalized between June 2017 and June 2018, inclusive, with code status changed from Full Code to DNR. For patients with more than one hospitalization during this study interval, only the first hospitalization when DNR was ordered was included in this analysis. MAIN MEASURES: Completion of POLST orders by time of discharge. KEY RESULTS: From 2017 to 2018, 160 adults had a change from Full Code to DNR status during index hospitalization and survived to discharge, most (156 patients) to a nursing care facility. Of these, only 50 (31.2%) had POLST orders provided at discharge. Documentation of informed refusal of intubation in addition to DNR status was a significant predictor (OR 4.1, 99% CI 1.5-11.0) of POLST orders on discharge, as was admission to a medical service compared with non-medical service (OR 3.2, 99% CI 1.1-12.2). Palliative care consultants, rather than primary providers on the hospital services, completed most POLST orders. CONCLUSIONS: Despite primary hospital providers engaging in conversations regarding resuscitation and entering DNR orders during hospitalization, the majority of patients in our study discharged to other care facilities without POLST orders. POLST orders are a simple palliative care tool available to primary hospital providers to help ensure continuity of plan of care at discharge for patients who wish to avoid invasive life-sustaining treatments and/or cardiopulmonary resuscitation.

Predicting Outcomes of In-Hospital Cardiac Arrest: Retrospective US Validation of the Good Outcome Following Attempted Resuscitation Score.

BACKGROUND: Providers should estimate a patient's chance of surviving an in-hospital cardiac arrest with good neurologic outcome when initially admitting a patient, in order to participate in shared decision making with patients about their code status. OBJECTIVE: To examine the utility of the "Good Outcome Following Attempted Resuscitation (GO-FAR)" score in predicting prognosis after in-hospital cardiac arrest in a US trauma center. DESIGN: Retrospective observational study SETTING: Level 1 trauma and academic hospital in Minneapolis, MN, USA PARTICIPANTS: All cases of pulseless in-hospital cardiac arrest occurring in adults (18 years or older) admitted to the hospital between Jan 2009 and Sept 2018 are included. For patients with more than one arrest, only the first was included in this analysis. MAIN MEASURES: For each patient with verified in-hospital cardiac arrest, we calculated a GO-FAR score based on variables present in the electronic health record at time of admission. Pre-determined outcomes included survival to discharge and survival to discharge with good neurologic outcome. KEY RESULTS: From 2009 to 2018, 403 adults suffered in-hospital cardiac arrest. A majority (65.5%) were male with a mean age of 60.3 years. Overall survival to discharge was 33.0%; survival to discharge with good neurologic outcome was 17.4%. GO-FAR score calculated at the time of admission correlated with survival to discharge with good neurologic outcome (AUC 0.68), which occurred in 5.3% of patients with below average survival likelihood by GO-FAR score, 22.5% with average survival likelihood, and 34.1% with above average survival likelihood. CONCLUSIONS: The GO-FAR score can estimate, at time of admission to the hospital, the probability that a patient will survive to discharge with good neurologic outcome after an in-hospital cardiac arrest. This prognostic information can help providers frame discussions with patients on admission regarding whether to attempt cardiopulmonary resuscitation in the event of cardiac arrest.

Managing stable COPD in 2009: incorporating results from recent clinical studies into a goal-directed approach for clinicians.

Chronic obstructive pulmonary disease (COPD) is prevalent in primary care practice and an important cause of functional decline, hospitalizations, and death. Recent clinical trials of COPD therapy demonstrate the ability of bronchodilators (especially long-acting beta2-agonists and anticholinergics), either alone or in combination with inhaled corticosteroids, to achieve the goals of managing stable disease. These management goals include: symptom relief, improvement in exercise tolerance and health status, prevention of exacerbations and progression of disease, and reduction in mortality. Recent studies of COPD treatment also provide important safety information to help clinicians address patient concerns about treatment risks. We reviewed recent clinical trials to develop concepts of care for the non-specialist clinician managing patients with stable COPD.

Impact of preoperative smoking status on postoperative complication rates and pulmonary function test results 1-year following pulmonary resection for non-small cell lung cancer.

There is a lack of evidence in the literature regarding the impact of preoperative smoking status on pulmonary function test (PFT) results 1 year after resection for non-small cell lung cancer (NSCLC). Furthermore, there is disagreement in the literature regarding the impact of preoperative smoking cessation on postoperative complication rates. We performed a single-institution retrospective review of all NSCLC patients who underwent resection from April 2000 through April 2006. Timing of smoking cessation was stratified as follows: smoking cessation more than a month before surgery (Distant Smokers), smoking cessation within a month before surgery (Recent Smokers), and failure to achieve smoking cessation before surgery (Current Smokers). During the study period, 213 patients underwent NSCLC resection, 121 of whom (all males; mean age, 67.4 years) completed pre- and postoperative PFTs. After adjusting for potential confounding covariates (age, type of resection, and use of radiation therapy), we noted no significant difference (p>0.40) between groups after resection with regard to either relative (-12.20+/-15.77L [Distant Smokers], -15.38+/-19.38L [Recent Smokers], -9.61+/-15.54L [Current Smokers]) or absolute changes in percent predicted forced expiratory volume in 1s (-0.14+/-0.20L [Distant Smokers], -0.18+/-0.19L [Recent Smokers], -0.12+/-0.20L [Current Smokers]). Because 92 patients did not complete postoperative PFTs, we performed a stratified analysis to assess for selection bias; as compared with those who completed PFTs, baseline PFT results did not significantly differ. We found no significant differences between the 3 groups with regard the overall rate of postoperative complications or the rate of any specific postoperative complication. In conclusion, smoking cessation immediately before NSCLC resection does not significantly impact postoperative pulmonary complication rates or 1-year postoperative PFT results and therefore should not be a reason to delay surgical resection.

Contemporary issues in the diagnosis and treatment of obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a common disease associated with significant morbidity and use of health care resources. Therapy with continuous positive airway pressure (CPAP) devices has low risk and a potentially large benefit in treating this disease. The Centers for Medicare and Medicaid Services (CMS) recently issued a memo revising their earlier position that authorized payment for CPAP only if formal polysomnography (PSG) was performed and was diagnostic for OSA. The revised memo states that CMS will be pay for CPAP therapy for 12 weeks (and subsequently if OSA improves) for adults diagnosed with either PSG or with unattended home sleep monitoring devices. The use of portable home monitoring devices can greatly increase access to diagnosis and treatment of OSA. However, these devices must be used as part of a comprehensive sleep evaluation program that includes access to board-certified sleep specialists, PSG facilities, and therapists experienced in fitting and troubleshooting CPAP devices.

The current approach to the diagnosis of pulmonary embolism: lessons from PIOPED II.

The rapid diagnosis of PE is essential to reducing the significant morbidity and mortality of this disease. The recently published PIOPED II reinforces the important lesson of assessing pretest clinical probability to correctly interpret test results, and supports a central role of CT angiography in patients with clinically suspected PE. The diagnostic algorithm discussed in this review allows clinicians to utilize the available diagnostic resources practically and efficiently to quickly diagnose and treat PE.

Formoterol fumarate inhalation solution (Perforomist) for COPD.

Formoterol fumarate is an effective treatment for chronic obstructive pulmonary disease (COPD) patients with moderate or greater severity of airflow obstruction. Published studies indicate that formoterol has a rapid onset of bronchodilation, which may enhance compliance, and sustained bronchodilation over 12 h, which produces a cumulative effect when inhaled twice daily. With long-term use, formoterol fumarate increases trough forced expiratory volume in 1 s and improves measures of hyperinflation, which correlate with relief of symptoms and a decreased need for additional short-acting bronchodilators as rescue treatment. The combination of formoterol with anticholinergic bronchodilators, especially the long-acting anticholinergic tiotropium, appears to further improve bronchodilation, decrease hyperinflation, improve symptoms and decrease the need for rescue therapy, compared with either agent alone. The availability of formoterol fumarate inhalation solution (Perforomist) for treatment of COPD now extends these benefits to patients who prefer nebulizer therapy and/or cannot use metered-dose or dry-powder inhalers effectively.

Humoral responses to oxidized low-density lipoprotein and related bacterial antigens after pneumococcal vaccine.

Antibodies to oxidized low-density lipoprotein (oxLDL) may modulate the development of atherosclerosis. Antibodies to oxLDL may also react with cell wall polysaccharides (CWPS) of Streptococcus pneumoniae because both antigens share a common phosphorylcholine moiety. In hypercholesteremic mice, immunization with pneumococcal organisms elicited antibodies to oxLDL and protection against atherosclerosis. In humans, we determined whether the widely used adult pneumococcal polysaccharide vaccine augmented antibodies to oxLDL, CWPS, and phosphorylcholine, providing the potential to retard atherogenesis. Before and 4 weeks after pneumococcal vaccination of 23 healthy adults (11 smokers and 12 matched nonsmokers), we characterized IgG, IgM, and IgA to pneumococcal capsular polysaccharides, CWPS, and phosphorylcholine, IgG and IgM to oxLDL, and fasting serum lipids. The pneumococcal vaccine elicited significant increases in each antibody class to surface capsular polysaccharides. In contrast, only IgG to CWPS increased modestly and only among smokers. Moreover, antibodies to neither phosphorylcholine nor oxLDL increased consistently in either group. The pneumococcal polysaccharide vaccine effectively elicits antibodies to the bacterial capsule. The vaccine had no effect on serum lipids. The vaccine did not augment antibodies to CWPS, to its component phosphorylcholine, or to oxLDL, which are antibodies that have been proposed to modify the uptake of oxLDL by macrophages and the pathogenesis of atherosclerosis.

Advanced age does not exclude lobectomy for non-small cell lung carcinoma.

STUDY OBJECTIVES: Localized non-small cell lung carcinoma (NSCLC) is best treated by complete surgical resection, commonly requiring lobectomy. The impact of lobectomy on the health status of the elderly patient is not well-characterized. The aim of this study was to compare the effect of lobectomy in elderly patients (> or = 70 years of age) and younger patients (< 70 years of age) on their pulmonary function and functional status 1 year following surgery. DESIGN: One hundred forty patients underwent lobectomy for NSCLC at the Minneapolis Veterans Affairs Medical Center from January 1999 to December 2003. All patients underwent pulmonary function tests (PFTs) and functional status assessment using Karnofsky scores (KS) that were assessed preoperatively. Sixty-three of 140 lobectomy patients were available 1 year postoperatively for reevaluation by PFTs and KS. RESULTS: There was no statistical difference between groups in either the pulmonary function or functional status testing results at 1 year after undergoing lobectomy. FVC decreased by 14% in the elderly patient and by 9% in the younger patient group. FEV1 decreased by 19% in elderly patients and by 13% in younger patients. Functional status declined for two older patients (8%), who dropped their KS from 80 to 100% (normal activity without limitation) to 40 to 70% (unable to work, but able to care of self at home). Nine of the younger patients (24%) had KS drop from 80 to 100% to 40 to 70%. There was one perioperative death (30-day mortality rate for the study groups, 1.5%). CONCLUSIONS: Elderly patients > or = 70 years of age undergoing lobectomy for NSCLC had similar PFT results and functional status as younger patients < 70 years of age 1 year after undergoing surgery. Curative resection should not be denied based on age alone.

The effect of tumor necrosis factor blockade on the response to pneumococcal vaccination in patients with rheumatoid arthritis and ankylosing spondylitis.

OBJECTIVE: To assess the effect of anti-tumor necrosis factor (TNF) alpha therapies on the immunogenicity of pneumococcal vaccination in patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS). METHODS: A group of 16 consecutive patients (11 with RA and 5 with AS) treated either with infliximab or etanercept, and a control group of 17 age-matched RA patients treated with disease-modifying medications other than anti-TNF-alpha, received intradeltoid injection with 0.5 mL of pneumococcal vaccine. Pneumococcal polysaccharide (PPS)-specific IgG to 7 vaccine PPS (representing high- and low-prevalence serotypes) was measured by enzyme-linked immunosorbent assay in sera obtained before and 1 month after pneumococcal immunization. RESULTS: One month after vaccination, both groups had significant increases in the geometric mean concentration of capsule PPS-specific antibody and in the mean fold increase in antibody levels to all 7 serotypes, compared with prevaccination levels. However, compared with the control group, the TNF-alpha blockade-treated patients tended to have lower antibody increases for all the serotypes tested except serotype 14. In addition, lower proportions of TNF-alpha blockade-treated patients responded to pneumococcal vaccination compared with patients on other therapies. Similarly, more TNF-alpha blockade-treated patients were poor responders compared with patients not on anti-TNF-alpha treatment. CONCLUSION: Treatment of groups of patients with etanercept or infliximab does not impair their mean antibody responses to pneumococcal vaccination. However, a larger proportion of RA patients may not respond adequately to pneumococcal vaccination once on TNF-alpha blockade therapies. Consequently, pneumococcal vaccination before starting TNF-alpha blockade therapy is recommended.

Classifying solitary pulmonary nodules. New imaging methods to distinguish malignant, benign lesions.

Physicians often are faced with determining benignity or malignancy in solitary pulmonary nodules in order to refer patients appropriately for curative resection of early-stage malignant nodules and to avoid the morbidity and mortality of a surgical procedure for benign nodules. Nodules are easily deemed benign when they are unchanged on chest radiographs over 2 years or have symmetrical patterns of calcification or central fat on chest CT. Similarly, growing, spiculated lesions in older patients with an extensive smoking history or other risk factors for cancer are easily recognized as likely to be malignant. However, solitary pulmonary nodules classified as indeterminate after consideration of radiologic characteristics and patient risk factors have traditionally posed a diagnostic dilemma. The use of newer imaging modalities, including contrast-enhanced chest CT, fluorodeoxyglucose PET, and technetium Tc 99m SPECT, can help distinguish benign nodules from those that are malignant.

Reimmunization with 23-valent pneumococcal vaccine for patients infected with human immunodeficiency virus type 1: clinical, immunologic, and virologic responses.

We determined the immunogenicity and safety of reimmunization with the 23-valent polysaccharide pneumococcal vaccine in patients infected with human immunodeficiency virus type 1 (HIV-1). Patients immunized >5 years earlier (initially within 1 year of HIV-1 seroconversion) were randomized to receive vaccine (n=57) or placebo (n=30). Persons with recent HIV-1 seroconversion (n=14) were immunized for the first time. Preimmunization levels of capsule-specific immunoglobulin G were similar in all groups. Reimmunized patients showed a significantly lower frequency and magnitude of antibody responses compared with persons with recent HIV-1 seroconversion. Reimmunized patients did not show adverse virologic or immunologic changes, but some reported local discomfort (15%) or fever (8%). Thus, the limited responses after reimmunization of HIV-1-infected patients with the current 23-valent vaccine mandates the need for a more effective reimmunization schedule, more immunogenic vaccines, or other behavioral and therapeutic interventions.

Immunogenicity and safety of pneumococcal vaccination in patients with rheumatoid arthritis or systemic lupus erythematosus.

Prevention of bacterial infection, which is a leading cause of morbidity in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), is a priority. However, the safety and immunogenicity of the pneumococcal vaccine in such patients remain controversial. We evaluated the currently available pneumococcal vaccine in patients with RA or SLE. Pneumococcal vaccination was not associated with an appreciable deterioration in any clinical or laboratory measure of disease activity in either group. One month after vaccination, patients in both groups had significant increases in geometric mean concentrations of pneumococcal polysaccharide-specific IgG to all 7 serotypes tested, as did control subjects. However, 14 (33.3%) of 42 patients with RA and 5 (20.8%) of 24 patients with SLE responded either to none or to only 1 of the 7 polysaccharides. Pneumococcal vaccination is generally safe and immunogenic in patients with RA or SLE, but a subset of patients may remain unprotected by the currently available vaccine.